Sight-threatening Eye Disease Research Articles

Improving Diabetic Retinopathy Screening Ratios Using Telemedicine-Based Digital Retinal Imaging Technology

To evaluate the impact of a telemedicine, digital retinal imaging strategy on diabetic retinopathy screening rates in an inner-city primary care clinic. This retrospective cohort study included all diabetic patients aged > or = 18 years (n = 495) seen at Vine Hill Community Clinic between 1 September 2003 and 31 August 2004. Patients were offered ophthalmology referral or digital screening. Patients choosing referral received the next available (within 3 months) appointment at the Vanderbilt Eye Clinic; patients choosing digital screening were screened during the visit. Retinal screening was documented for 293 (59.2%) patients, a significant improvement compared with the 23% baseline rate. Of 293 patients screened, 92 (31.4%) were screened in ophthalmology, and 201 (68.6%) were digitally screened. Among the 201 digitally screened patients, 104 (51.7%) screened negative and were advised to rescreen in 1 year, 75 (37.3%) screened positive and were nonurgently referred to ophthalmology, and 22 (11.0%) screened positive for sight-threatening eye disease and were urgently referred for ophthalmological follow-up. Digital imaging technical failure rate was 0.5%. Referral status was associated with race/ethnicity (chi2 = 7.9, P < 0.02) with whites more likely to screen negative than non-whites (62.4 vs. 47.8%, respectively). Sight-threatening disease among non-whites (14.7%) was more than double that observed for whites (5.9%). Digital imaging technology in the primary care visit can significantly improve screening rates over conventional methods, increase access to recommended diabetic eye care, and focus specialty care on medically indigent patients with greatest need.

Vision rehabilitation: Current research activities helping to meet needs of veterans with visual impairments

According to the National Eye Institute of the National Institutes of Health, Americans are facing increasing rates of visual impairment and blindness from age-related diseases. More than 1 million Americans aged 40 and over are currently blind and an additional 2.4 million are visually impaired. These numbers are expected to double over the next 30 years as the baby-boomer generation ages. Vision Problems in the U.S. (http://www.nei.nih.gov/eyedata/pdf/VPUS.pdf), a report on the prevalence of sight-threatening eye disease in Americans, addresses the leading causes of visual impairment and legal blindness, including-- * Diabetic retinopathy, a leading cause of visual impairment in the industrialized world among people aged 25 to 74. * Age-related macular degeneration, the most common cause of visual impairment in Americans 60 and older. * Cataract, the leading cause of blindness in the world, although not a significant factor in the United States. * Glaucoma, a chronic disease that often requires life-long treatment. The articles in this special issue on vision address three general areas: screening for diabetic retinopathy using teleretinal imaging, basic research on treating and preventing vision loss, and management of patients with low vision or legal blindness. In addition to an increased prevalence of vision loss, many older adults have concomitant hearing loss that results in a dual sensory impairment. Dual sensory impairment affects anywhere from 5 to 21 percent of older adults. Although much lower in prevalence than vision loss, this combined vision and hearing loss is associated with much greater functional limitations in the performance of activities of daily living (ADL). Visual and aural rehabilitation programs must concomitantly compensate for these changes and improve functional competence in everyday tasks. The Veterans Health Administration (VHA) has been involved in the VHA Teleretinal Imaging Program, a project that uses telemedicine to screen veterans with diabetes for diabetic retinopathy. This project seeks to capture veterans with diabetes who are not being examined by optometrists and/or ophthalmologists for diabetic retinopathy. Retinal images of these veterans with diabetes will be obtained while they are seen in a primary care clinic setting. Afterward, these images will be transmitted to a reading site for reading by an optometrist or ophthalmologist. Pilot programs were started in Veterans Integrated Service Network (VISN) 1 and VISN 20. The success of these initial programs led the VHA to expand the VHA Teleretinal Imaging Program within the VHA Office of Care Coordination. In each of the 17 selected VISNs, the VHA will place six imaging cameras at various locations along with imagers and readers who have received standardized education at the Boston Department of Veterans Affairs (VA) Teleretinal Imaging Training Center. As of September 2006, more than 70 cameras have been installed in 13 VISNs. More than 10,000 veterans' retinal images have been taken and read by specially trained eye doctors, optometrists, and ophthalmologists. The VHA Teleretinal Imaging Program is anticipated to be fully implemented in early 2007 and to improve access for our diabetic patients. When visual impairment and blindness occur despite preventive measures or following medical therapy and/or surgical intervention, one must determine the degree of the patient's visual impairment and provide vision rehabilitation services. …

Evidence for an inflammatory process in age-related macular degeneration gains new support

A ge-related macular degeneration (AMD) is a sight-threatening eye disease that affects large numbers of the human population over the age of 65. It is particularly prevalent in European countries and in the United States, which has a large population of European descent. However, its incidence is increasing in Japan, as well, for reasons that are not clear (1). Currently, it is estimated that 1.75 million individuals suffer from this disease in the United States, and 7 million are said to be “at risk” (2). The emotional and socioeconomic impact of AMD is large because of reading and driving impairment caused by this disease, which primarily affects central (straight on) rather than peripheral (side) vision. The disease involves the macula of the retina, a region ≈6 mm in diameter that lies within the central axis of vision. The macula has an abundance of densely packed, specialized neurons called photoreceptor cells (rods and cones) that receive the visual stimulus and initiate a complicated cascade of biochemical and ionic events (phototransduction) that begin the visual process. A stratum of cells called the retinal pigment epithelium (RPE), resting like a single layer of paving stones on a bed of extracellular matrix called Bruch's membrane, separates the photoreceptor cells from their blood supply in the choroid (middle layer) of the eye wall. It is within the RPE layer and Bruch's membrane that the mischief leading to AMD is thought to begin. Risk factors for AMD are well established from epidemiologic studies (3). In addition to advanced age, the risk factors include ocular pigmentation, dietary factors, a positive family history for AMD, high blood pressure, and smoking. Insights into the etiology of AMD have been slow in development because of the late onset of the disease. However, recent access to the human genomic sequence has …

Evaluation of a local optometric diabetic retinopathy screening service.

To determine the sensitivity and specificity for sight-threatening eye disease (STED) of the diabetic retinopathy screening scheme for Stockport during the period 1 April 2000 to 31 March 2001. A random sample of screen-negative patients was recalled for further assessment by consultant ophthalmologists. Screen-positive patients, who were referred, were tracked through the hospital system to determine the outcome. In a 12-month period, 3510 individuals with diabetes were screened, which is 1.2% of the district population. Sensitivity for STED was 75.8%[95% confidence interval (CI) 49.3, 99.99] and specificity for STED was 99.0% (95% CI 98.6, 99.3). The current screening arrangements in Stockport are satisfactory in terms of sensitivity and specificity. Population coverage was 1.2% over 12 months and 1.5% over 15 months and needs to be improved. An integrated computerized register requires further development.

Ambulatory photographic screening for diabetic retinopathy in nursing homes.

To evaluate the feasibility and cost of screening for diabetic eye disease in homebound nursing home residents not attending a systematic screening programme. Postal survey identification of residents with diabetes in all nursing homes in Liverpool. An ophthalmologist and nurse performed Bailey-Lovie logmar visual acuity (VA), portable slit-lamp examination, fundus photography, and subjective assessment of ability to cooperate with treatment in a sample of homes. Modified Wisconsin photographic grading was performed. Screen-positive patients were invited to a dedicated assessment clinic. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy, or exudate within 1 disc diameter of fixation. A total of 54 (78%) nursing homes responded reporting 199/2427 (8.2%) residents with diabetes. Of these, 64/80 (80%) residents in 17 homes were examined: VA possible in 50 (78%); slit-lamp examination in 56 (88%); gradable photographs in at least one eye in 34 (53%); STED in 12 (35%) patients. In all, 35 (70%) patients had Snellen-equivalent VA worse than 6/12 in the better eye, of whom 13 (26%) were worse than 6/60. Of 29 screen positive patients, 12 attended the assessment clinic: one was unable to cooperate outside the home; 11 continue under ophthalmic review, four for previously undetected STED of which one listed for laser photocoagulation. Total cost pound 16,980; cost per screen event pound 60.30. Systematic eye screening in homebound patients with diabetes detects disease but follow-up and treatment is only feasible in a small proportion and at high cost. Alternative targeted assessment is recommended.

Prevalence of diabetic eye disease in patients entering a systematic primary care-based eye screening programme.

Large-scale, baseline prevalence measurements in a population at the institution of systematic retinal screening are currently unavailable. We report the prevalence of all grades of retinopathy at entry into a systematic primary care-based diabetic eye screening programme. Primary care-based photographic screening utilizing mydriasis and three-field non-stereoscopic photography for all patients with diabetes (except those under continuing care of an ophthalmologist) in Liverpool. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy or exudates within one disc diameter of the centre of fovea. Type 1 diabetes mellitus (DM) (n = 831): baseline prevalence (95% confidence interval (CI)) of any retinopathy, proliferative diabetic retinopathy (PDR) and STED was 45.7% (42.3-49.1), 3.7% (2.4-5.0) and 16.4% (13.9-18.9), respectively. Presence of STED was associated with increased disease duration (odds ratio (OR) 1.09 per year; P < 0.0001) and higher in men (OR 2.15; P = 0.001). Type 2 DM (n = 7231): baseline prevalence (95% CI) of any retinopathy, PDR and STED was 25.3% (24.3-26.3), 0.5% (0.3-0.7) and 6.0% (5.5-6.5), respectively. Presence of STED was associated with longer time since diagnosis of DM (OR 1.03; P < 0.0001) and insulin use (OR 2.46; P < 0.0001). This study provides baseline information for health providers on prevalence of all grades of retinopathy and STED in a large population at the establishment of systematic screening. Baseline prevalence of STED was high and highest in patients with a longer disease duration in both Type 1 and Type 2 DM.

Does direct ophthalmoscopy improve retinal screening for diabetic eye disease by retinal photography?

To identify whether after performing retinal photography, direct ophthalmoscopy can improve the yield of screening for the detection of sight-threatening diabetic eye disease (STDED). Patients (n = 408) who had previously received both dilated direct ophthalmoscopy by a diabetologist and retinal photography graded by a diabetologist within 3 months of each other were included. The results of the other screening modality were not available to the grader/screener. The first 308 patients were consecutive attendees at the clinic who fulfilled the study criteria and 100 were selected because they were identified as having potential STDED by either one of these modalities. An ophthalmologist using slit lamp biomicroscopy then examined patients identified with potential STDED. In 357 (88%) patients there was agreement between the two modalities about whether referral to an ophthalmologist was required (kappa 0.62). Retinal photography identified 38 patients for referral to ophthalmology which ophthalmoscopy missed. Of these, the ophthalmologist agreed that STDED was present in 32 (84%) and four patients required early laser. Ophthalmoscopy identified 13 patients for referral who were not identified by photography. Of these, the ophthalmologist agreed with the diabetologist that STDED was present in seven (54%) and one patient required early laser. Ophthalmoscopy may identify the occasional patient with diabetes who has STDED which is missed by retinal photography. For a systematic retinal screening programme, adding ophthalmoscopy to retinal photography will increase false-positive referrals and is likely to detect only a few extra patients requiring laser.

Evaluation of a district-wide screening programme for diabetic retinopathy utilizing trained optometrists using slit-lamp and Volk lenses.

Debate exists about the optimum way to screen for diabetic retinopathy. Cameras produce a permanent record, but offer patients less choice about when and where to be screened. Optometrists offer flexibility but sensitivity and specificity of schemes have varied considerably, perhaps because of variability in screening methodology and that there is frequently no quality assurance programme. To audit our district-wide (population 340000) screening programme for diabetic retinopathy against national targets: sensitivity > 80%, specificity > 95% and referral to review < 3 months. Trained optometrists performed slit-lamp examination with Volk lenses (78 dioptre) with standardized reporting. Audit was by ophthalmologist with slit-lamp and Volk lenses through dilated pupils. We examined 872 eyes of 439 patients; 64% were normal, 29% background diabetic retinopathy, 7% sight-threatening eye disease (STED). Sixty-three percent of patients were seen within 6 months of the original screen. Of these, sensitivity for any retinopathy was 72%, specificity 77%, positive predictive value (PPV) 53%, negative predictive value (NPV) 88%. For STED, in this group, sensitivity was 87% and specificity 91%, PPV 30%, NPV 99%. Median interval referral to ophthalmological review was 11.5 weeks with 73% reviewed in under the 13-week target. Of those referred 25% received laser therapy. Eleven patients found to have referable eye disease at their initial screen were not referred to an ophthalmologist by their GP. We conclude that effective district-wide screening for diabetic retinopathy by optometrists using slit-lamp and Volk lenses is possible; however, only 36% of identified people with diabetes in the district were screened over a 4-year period.

Cost effectiveness analysis of screening for sight threatening diabetic eye disease

Objective: To measure the cost effectiveness of systematic photographic screening for sight threatening diabetic eye disease compared with existing practice.Design: Cost effectiveness analysisSetting: Liverpool.Subjects: A target population of 5000 diabetic...

Behçet's syndrome: a multidisciplinary approach to clinical care.

Behçet's syndrome is a multisystem disorder characterized by recurrent orogenital ulceration and an occlusive vasculitis. Histologically, there is a combination of a perivascular lymphocytic infiltration with endothelial cell damage coupled with a pro-thrombotic tendency. We present a multidisciplinary approach to the management of Behçet's syndrome, and compare our findings with other published studies. Over a nine-year period, 50 patients with Behçet's syndrome were followed in a multidisciplinary combined clinic. Patients were assessed by an ophthalmologist, a rheumatologist and a specialist in oral medicine. Data on disease activity and damage were collected using a standardized proforma for each specialty. Mean age of onset was 30 years; 56% were male. Recurrent oral ulceration was the commonest manifestation and the presenting feature in 76%. The commonest second systems involved were genital mucosae and eyes. We found a larger proportion of patients with ophthalmic (80%) and central nervous system (14%) manifestations compared with many other studies. There was an association between central nervous system and thrombotic events (p<0.001). Our multidisciplinary approach allowed us to keep each system involved in Behçet's syndrome under careful review. The development of recurrent sight-threatening eye disease was unpredictable and occurred despite aggressive immunosuppression.

Prevalence of diabetic eye disease in an inner city population: the Liverpool Diabetic Eye Study.

To measure the population prevalence of diabetic eye disease in an inner city setting. As part of a systematic screening programme all adult diabetic patients in four general practices were invited to attend for slit-lamp biomicroscopy by a retinal specialist. Data on non-attenders were available from community-based photography. Of 395 diabetic patients identified, 326 attended biomicroscopy with photographic data available on a further 31, giving a 90% compliance rate. Point prevalence of diabetes in the target population was 12.4/ 1000. Demographic data included: mean age 60 years (range 13-92 years); type of control: type I 49, type II insulin-requiring (IR) 40, type II non-insulin-requiring (NIR) 268. Prevalences were as follows: any retinopathy: of all diabetic patients 33.6%, type I 36.7%, type II IR 45.0%, type II NIR 31.3%; proliferative/ advanced: all 1.1%, type I 2.0%, type II IR 0, type II NIR 1.1%; clinically significant macular oedema: all 6.4%, type I 2.3%, type II IR 16.2%, type II NIR 5.7%. The percentage of patients with retinopathy requiring follow-up by an opthalmologist was 4.5%, and 9.2% had macular exudates within 1 disc diameter of fixation or significant circinate maculopathy. Sight-threatening diabetic eye disease (STED) was found in 13.4%. A visual acuity of < or = 6/24 in the better eye occurred in 12 (3.4%) patients and of < or = 6/60 in the better eye in 3 (0.8%). Compared with previous population studies, prevalences appear to have declined in type I, but remain high in type II diabetic patients and especially in those requiring insulin.

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study.

Diabetic retinopathy remains the most common cause of blindness in people of working age but the provision of high quality eye screening for diabetic patients is still erratic in many health districts in the UK. National consensus guidelines recommend comprehensive population coverage, high sensitivity (>80%), high specificity (>95%), agreed clinical criteria, referral procedures and centralized data collection to facilitate audit. This study looks at the effectiveness of implementing a prompted recall programme for retinal screening in an inner-city district of North London. The scheme uses trained, accredited optometrists to screen patients with diabetes who are looked after in the community by their general practitioner. During the first 17 months of the scheme, 63 optometrists attended training and gained accreditation. Of the 666 patients recruited, 645 were scheduled for screening and 536 (83%) attended. Fourteen per cent of patients screened were found to have background retinopathy and 2.3% sight-threatening eye disease. In two audits, carried out 15 months apart in a random sample of GP practices, the incidence of recorded dilated fundoscopy increased from 48% at baseline to 56%, an increase of 8% (95% CIs 2%-14%). For referable eye disease, the sensitivity of this screening technique was 100%, the specificity 94% (95% CIs 90%-98%), the positive predictive value 79% (95% CIs 72%-86%) and the negative predictive value 100%. The administrative cost per case screened was Pound Sterling 12.60 (excluding clinical costs and any additional optometry payment).

Detection of sight-threatening diabetic eye disease.

Blindness due to diabetes mellitus is potentially preventable in the majority of patient. Early detection of sight-threatening changes is associated with a better outcome, indicating the need to screen for retinopathy. At least 50% of diabetic patients do not attend a hospital, so that diabetologists and ophthalmologists are unable to screen the diabetic population comprehensively. Although in theory all patients has access to general practitioners, these may lack training or confidence to screen for retinopathy. Hospital based or community optometrists using direct ophthalmoscopy or slit lamps and technicians performing fundus photography are alternatives which may be more effective. Further studies are required to examine the effectiveness of optometry screening. Initial studies using fundus photography raised concerns about the sensitivity of the technique, but these have been partially addressed by improvements in methodology and technology. As well as technicological effectiveness, factors affecting patient uptake of screening services still need to be addressed.

Screening for sight threatening eye disease

Screening for sight threatening eye disease

Cost effectiveness of screening modalities must be determined

EDITOR,—S P Harding and colleagues recommend a three field photographic screening protocol with use of mydriatics to detect diabetic retinopathy.1 Despite the relatively high sensitivity (89%) reported for the detection of sight threatening eye disease with this method, the sensitivities …

Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool diabetic eye study

To evaluate different methods for community based screening for sight threatening diabetic eye disease. Prospective study. Mobile screening unit visiting inner city community clinics; hospital assessment clinic (tertiary centre). 395 diabetic patients registered with four general practices in an inner city location. Community based photography with mydriasis and direct ophthalmoscopy through dilated pupils by an experienced ophthalmologist, both compared with reference standard of slit lamp biomicroscopy by a consultant specialist in medical retinal disease. Sensitivity and specificity of screening method and prevalence of sight threatening diabetic eye disease (moderate preproliferative retinopathy, circinate maculopathy, exudate within 1 disc diameter of fixation, other diabetes related eye disease). 358 subjects underwent photography, 326 attended hospital clinic for ophthalmoscopy, and six were ungradable on photographs and biomicroscopy, leaving 320 for analysis. Of these 295 (91%) attended clinic within four months of photography. Sensitivity of detection of eye disease by photography was 89% (95% confidence interval 80% to 98%), significantly better than for direct ophthalmoscopy (65% (51% to 79%)). Analysis of patients with false negative results indicated possible improvement of photographic sensitivity to 93% by addition of stereoscopic macular pair photographs. Specificity of detection of sight threatening eye disease was 86% (82% to 90%) for photography and 97% (95% to 99%) for direct ophthalmoscopy. Since high sensitivity is essential for an effective screening programme, a photographic method should be considered as preferred option in national, community based screening programmes. Even in the hands of an experienced ophthalmologist, direct ophthalmoscopy is limited by weaknesses inherent to the instrument.

SYMPATHETIC OPHTHALMIA

To evaluate the efficacy of treatment on prevention of disease development and protection of visual outcomes in patients suffering from sympathetic ophthalmia.Retrospective case.Four patients with sympathetic ophthalmia were treated in our department from 1999 to 2004. All patients were men with the mean age 27.5 years (15-49 years). In two patients, there was a history of penetrating eye injury prior to the onset of sympathetic ophthalmia, in other two patients sympathetic ophthalmia occurred after eye surgery (pars plana vitrectomy), with no previous ocular trauma. Two patients were treated with monotherapy of corticosteroids; other two patients were commenced on combined immunosuppression. In all these cases, the therapy was effective.Sympathetic ophthalmia is a rare, sight-threatening eye disease. Among the triggering factors dominates penetrating eye injury, however, there is currently an increase in the number of cases with sympathetic ophthalmia following eye surgery, mainly pars plana vitrectomy. Early introduction of immunosuppressive treatment can get the disease under control, prevent the development of intraocular inflammation and improve visual outcomes.